Pennsylvania Department of Health
CATHEDRAL VILLAGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CATHEDRAL VILLAGE
Inspection Results For:

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CATHEDRAL VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to one facility reported incident, completed on March 25, 2026, it was determined that facility was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations: Based on review of clinical documentation and interviews with staff, it was determined that the facility did not ensure that one resident was free from accidents and hazards related to inappropriate transfers for one of five residents reviewed. This deficiency is cited as past non-compliance. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on October 31, 2021, and had diagnoses including Alzheimer's disease (progressive degenerative disease of the brain, resulting in loss of reality contact), chronic kidney disease, and depression (major loss of interest inpleasurable activities). Review of facility documentation submitted to the State Survey Agency on February 28, 2026, revealed "[Resident R1] was gently guided to the floor matt by one aide during transfer from bed to chair. When reviewing incident and care plan IDT (Inter-Disciplinary Team) noted that care plan reflects transfer utilizing 2 person stand up lift. Resident did not sustain any injury. Resident was immediately assessed, no injuries noted. Vital Signs stable. MD (physician) and responsible party notified. Therapy to re evaluate to ensure the use of stand up lift is the most appropriate mode of transfer." Review of the incident investigation confirmed that Nurse aide, Employee E3 was assisting the resident with morning care on February 28, 2026. A witness statement from Nurse aide, Employee E3, emailed on March 2, 2026, stated "[I] was assistanting [Resident R1] to get up for the day he was sitting on the edge of the bed stood him up he couldn't stand so I assisted him down the floor and got staff help to get him up go report from [Employee E4] he was stand and pivot". A record of a verbal statement from Nurse aide, Employee E4, dated March 2, 2026, stated "I thought (he/she) was a pivot to the chairaide, Employee E3] did not ask anyone for any assistance in putting the resident in the chair". A written statement from Nurse aide, Employee E4, signed March 2, 2026, stated "I gave report at the start of shift to the CNA (Nurse aide) on [Resident R1]. She also had a copy of the assignment and also had access to the Kardex (electronic system which contains documentation on the care needs of a resident)". A statement from Licensed nurse, Employee E5, stated "Pt (patient) has 2 cuts on (her/his) forehead, above the [right] &; [left] eyes, a bump in between the cuts, &; a black eyeMouth was bleeding too, I wiped the blood and noticed that the patient has a small cut insider (her/hids [right] upper mouthchecked the side of the bed &; noticed that there was blood on the [right] corner side of the bed frame." Review of the care plan for Resident R1 revealed an intervention dated July 21, 2025, that stated "The resident requires sit to stand lift (a type of mechanical lift that enables safe transfer between surfaces) with 2 staff assistance for transfers." Review of the documentation related to transfers for Resident R1 revealed that from February 24 through February 28, 2026, that out of nine documented assisted transfers, four were appropriately documented as a two person assist, while five were documented as one person assist. For those same nine transfers, four were appropriately documented as total dependence on staff, while three were documented as extensive assistance (resident is involved in the transfer, but staff bear some of the resident's weight during the activity), one was documented as independent (the staff provides no help or supervision), and one was documented as not applicable. During an interview on March 25, 2026, at 11:15 a.m., the Nursing Home Administrator (NHA), Employee E1, revealed that during the investigation, Nurse aide, Employee E3 was found to have not appropriately ensured that the method of transfer for Resident R1 was consistent with the plan of care. The NHA also confirmed that any mechanical lift requires two nursing staff to operate. Documentation was presented on March 25, 2026, by the NHA, alleging that the facility had initiated a plan of correction on March 2, 2026, related transfer safety. The facility alleged a date of compliance of March 5, 2026. The plan of correction stated the following: Resident lowered to the floor matt during transfer; no injuries. Care plan reviewed and found to be 2 person stand up lift for all transfers.Care plans will be reviewed for transfers using stand up lifts to ensure they are linked to Kardex. Completion date: 3/4/26The Director of Nursing or Designee will re educate the nursing staff on utilizing Kardex for transfer status. Return demonstration from licensed nurses and care aides in regards to accessing Kardex. Completed: 3/4/26.The Director of Nursing or Designee will complete a random audit on 3 residents weekly x 4 weeks and then monthly x 2 months who are stand up lift transfers to ensure stand up lift transfer is noted on the assignment sheets. Audits will be forwarded to the Quality Assurance Team for review and any recommendations needed."Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of appropriate verification method for transfer status. Random staff and resident interviews were conducted to verify compliance with the plan of correction. QAPI records reviewed to verify ongoing monitoring. Observations on the units revealed staff to be utilizing the Kardex to verify transfer status. Further observation confirmed residents were being safely transferred in accordance with the plan of care. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa. Code 201.14. (a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management

Plan of Correction - To be completed: 04/07/2026

Past noncompliance: no plan of correction required.

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